CARE HOME ADULTS 18-65
Cashel Cottage 39 Raffin Lane Pewsey Wiltshire SN9 5HJ Lead Inspector
Tim Goadby Unannounced Inspection 1st March 2006 13:00 Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Cashel Cottage Address 39 Raffin Lane Pewsey Wiltshire SN9 5HJ 01672 563710 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Steven@StevenAbbott.wanadoo.co.uk Mrs Jane Abbott Mr Patrick Jones Mrs Jane Abbott Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: Valued Lives is a private organisation, which operates five care homes for adults with learning disability. All are small establishments, intended to offer a normal domestic lifestyle. The main lead for the organisation is taken by one of the registered persons, Mrs Jane Abbott. She is supported by other senior colleagues, including family members. Each of the Valued Lives homes is situated in Pewsey, or nearby small villages. Pewsey itself offers a range of amenities. The market towns of Marlborough or Devizes are within 15 minutes’ drive. Or, slightly further afield, there are the larger centres of Salisbury and Swindon. The organisation has a number of vehicles used to transport service users, who contribute towards the costs of these. Most service users now cared for by the organisation have been with them for a number of years. Time may have been spent in more than one of the homes that Valued Lives operates. Valued Lives also operates the Activity, Opportunity & Development centre (AOD). This is a day care facility which most of the organisation’s service users access, for at least part of each week. They pay a small weekly sum towards this. The unit is attached to the home in Ball Road, Pewsey. Cashel Cottage in Raffin Lane, Pewsey, cares for up to four service users. The present occupants are all female. All bedrooms are on the first floor. There is one shared bedroom. The bathroom is upstairs, whilst a new shower has recently been provided downstairs. There is a small bedroom where staff sleep in. Communal space is on the ground floor. There is also a large garden. Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place in March 2006. All five Valued Lives services were inspected over the course of the day. There are many common features across the organisation. So, where appropriate, inspection findings have been applied to each establishment. A total of 6 hours was spent carrying out these unannounced visits. The following inspection methods have been used in the production of this report: indirect observation; sampling of records; discussions with service users, staff and management. What the service does well: What has improved since the last inspection?
Since the inspection of September 2005 there has been various regulatory contact with Cashel Cottage. This included an additional inspection visit in November 2005, in response to the raising of concerns by other agencies about the care of one service user. The individual’s mobility had decreased, and they were having to sleep downstairs whilst awaiting medical treatment.
Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 6 At the November inspection the temporary care arrangements were considered to be generally suitable. Requirements were set regarding input from appropriate professionals; and for evidence to support the use of bed sides. These are now met. The organisation has had input from the local continence advisor. As a result, some changes have been made in the support given to any service users with needs in this area. There is ongoing liaison with the advisor, to ensure that people benefit from appropriate care. There has also been advice and input from the occupational therapist, to identify suitable equipment and techniques for giving safe support to service users with impaired mobility. The installation of a ground floor shower is now complete, and this forms a useful resource for the home. It ensures that effective personal hygiene can be maintained for the individual who is currently unable to use the stairs. The use of bed sides is supported by a documented risk assessment, and written evidence of consent from the service user’s representative, which in this case is a family member. This upholds the required safety and good practice for any use of such equipment. Behaviour management strategies are being reviewed and updated. The organisation is now involving the local community learning disability nurse in this process. All service users have been referred for this input, which is to be given in order of identified priority. Progress has been made on the implementation of a quality assurance system. The organisation has condensed the tool purchased for this into a more manageable ten page booklet, which will form the basis of the approach to auditing all aspects of service delivery. What they could do better:
Care plans and associated information are comprehensive, but not always easy to work through. Condensing the range of documents, and making key current issues more prominent, would be helpful for accessibility. Where people have needs that are changing constantly, a system that enables quick reference to the latest position is beneficial. This will help to promote effective and consistent support to service users. Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 7 Service users are placed at risk by some deficits in practices for the management of medicines. There needs to be clear guidance in place about the use of any medication which is prescribed to be given ‘as required’. Because this means that a final administration decision has to be made by staff, it is important to show that these judgements are made consistently. Guidelines should be checked with the prescribing doctor, to ensure that they are in line with the actual intentions. From completion of a quality audit, the organisation needs to generate a development plan. This can focus on any identified strengths and deficits, across all areas of service delivery. Goals can then be set, against which future progress can be measured. This will provide evidence of a philosophy of continuous improvement, to the benefit of service users. It is important that information about individual choices, and any restrictions felt to be necessary, is in place, and kept under review. This will demonstrate that the approach taken is agreed by all relevant persons to be suitable to each service user. Signing and dating of key documents can contribute towards showing appropriate practice. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 Standards relating to admissions to the home were not applicable at this inspection. Service users have their needs and aspirations met by the home. Service users have individual terms and conditions of residence in the home. EVIDENCE: There have been no recent admissions to the home. All service users at Cashel Cottage have lived within Valued Lives for a number of years. They have therefore established their routines. There has also been continuity and stability in the staff team. Many have several years’ experience. This has given them a depth of knowledge regarding service users. Service users are given assistance and support with personal care as required. They are able to access a range of health care services. Relevant professionals and therapists are involved in addressing individual needs. Due to some changes in needs, one service user left the home for a period of assessment in a specialist facility shortly before this inspection. Their place at Cashel Cottage is being kept for them, pending the outcome of this. Education, occupation and leisure opportunities are all provided by the organisation.
Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 10 Valued Lives is in the process of implementing individual contracts for all service users. The documents are being signed by relevant representatives of the users, as review meetings take place. Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&7 Service users have their abilities, needs and goals reflected in their individual plans. Review is not always evidenced promptly, in response to changing needs, which creates the risk that some service users may not receive appropriate care. Service users can make choices and decisions in their daily lives. EVIDENCE: Valued Lives has developed an extensive care plan format, covering a full range of topics. Information relevant to each individual is set out under these headings. Where appropriate, risk assessments are also conducted on certain areas. Daily folders for each service user also contain a lot of relevant information. Key areas are monitored and charted. Ongoing care records contain a good level of detail about people’s health, mood, behaviour, and activities undertaken. There is evidence of consultation with other professionals, providing a clear picture of how somebody’s needs are identified and addressed.
Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 12 The amount of information in place means that it can be difficult to quickly identify current issues and themes for each individual. Where people have needs that are changing quite quickly, a system that enables quick reference to the latest position is beneficial. At this inspection, not all elements of one person’s care plans and risk assessments were updated to reflect recent changes in their needs. Although the person is temporarily unable to use the stairs, this is not made clear in their file, leaving scope for confusion. Guidelines for personal hygiene refer to use of the first floor bathroom, whereas the person is now using a new ground floor shower. The importance of good communication between staff and service users is emphasised to all Valued Lives’ employees. Each person is involved and consulted in discussions about their own care. All residents have an allocated staff keyworker, and monthly meetings take place between these pairings, to promote service user involvement in decision making. Some restrictions are in place. This includes locks on certain doors, for various safety reasons. This varies between the different homes, depending on the needs of service users. However, there are some practices which are applied across the board. For instance, disabling the flushing mechanisms of toilets, to monitor continence. Also, serving of hot drinks at cooled temperatures, to minimise risk of scalding. Individual agreement to these approaches has been secured via service users’ representatives. Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Service users are provided with a range of activities and opportunities, offering them full engagement with their local community. Service users are able to maintain and develop appropriate relationships with family and friends. Daily lives for service users have an appropriate balance between necessary routines, and individual choice. Service users are offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. EVIDENCE: Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 14 Valued Lives aims to meet all of its service users’ needs. Day care is provided in the Activity, Opportunity & Development centre (AOD), which is attached to Heads Meadow. Here, people are able to participate in a programme that includes a mix of craft activity, musical experience, story telling, and environmental awareness. Work includes annual projects, which result in something tangible that service users have been involved in producing. The organisation has invested in a range of materials and equipment that can be used for various sessions. The unit is facilitated by care staff. They do not have any specific training in the provision of a day service. But users appear to enjoy attending it. Additional external facilities are not routinely considered. Use of the AOD has decreased recently, for various reasons. The organisation is currently pursuing the possibility of acquiring alternative local premises from which to operate a day service facility. When not attending the AOD, people have one-to-one staff time to undertake other activities. Service users from different homes will link up for this. The sessions offered are based on the known likes and preferences of each user. Physical activities, such as trampolining, are accessed at a centre near Marlborough. There is regular use of community facilities, including local shops and pubs. Further afield, people access various leisure amenities. For instance, trips to the cinema or theatre, and ten pin bowling. Once a fortnight, most users attend a local club for people with learning disability. All service users’ birthdays are marked with parties. Key events in the year, such as Easter and Christmas, are also celebrated. All service users are given the opportunity of holidays at a caravan owned by the organisation. They pay an annual contribution towards its ground rental. They are then able to use it at no further cost, other than holiday spending money. The caravan can accommodate up to eight people at a time. But groups of staff and service users go in varying sizes. Length of break can also be tailored to individual needs. The caravan is also close enough to be able to bring someone home without great difficulty, if that is needed. Users may also have other holiday opportunities. Some go away with their own families. There are also regular activities in each home. Individual service users have activity boxes, containing items of interest to them. Hobbies include jigsaws, knitting, and writing. A number of service users have pets. In addition, animals are regularly present in each home. The organisation believes in the beneficial therapeutic effects of such contact.
Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 15 Service users are supported to maintain family contact as required. Various people have regular set arrangements for this. This may be at home, or involve users being taken to visit their families. The organisation provides transport if relatives live some distance away. Users are charged fuel costs for these journeys. This is usually shared, as a number of people will be on the same trip. In addition to these planned contacts, homes keep relatives informed of any significant issues affecting their family member. Families are always invited to attend review meetings for the relevant service users. They have also been involved in developing care plans, particularly by helping to compile people’s life histories. Peer support is gained within Valued Lives, or at the local Gateway club. Contact with people without learning disability, other than staff of the organisation, is gained when people access community facilities. Service users have their rights upheld in their daily lives. They are able to decide which activities they wish to participate in. Valued Lives has a clear strategy to promote healthy eating for all service users. The organisation believes its approach to have health benefits for all users. It is also seen as successful in minimising certain adverse behaviours. The eating plan promotes a diet free from additives and preservatives. It is also dairy and gluten free. Fresh fruit and vegetables are promoted. Well known brand labels are purchased, whose ingredients are felt to be of better quality. Service users mainly drink herbal teas, in preference to drinks such as tea and coffee. However, they may have these when out. Diet choices are also more relaxed when users go out for a meal. Service users participate in the choice of menu, from a range of suggested options. Pictures of the meals on offer are used to assist with this. The menu is drawn up for three months at a time. At mealtimes, staff eat alongside users. Support for individuals with particular needs has been devised with input from relevant professionals, such as the dietician, and the speech therapist for advice on swallowing difficulties. Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users are supported to address their personal and health care needs effectively. Medication is handled safely in the home. However, guidelines for the use of each ‘as required’ medication must be available for staff, to ensure a consistent approach. EVIDENCE: Service users are assisted with various levels of personal care and supervision. This varies depending on their individual abilities. People have established routines, such as their preferred time for getting up. Staff guidance may be needed if people have set appointments to be ready for. Assistance is given to choose clothes on a daily basis. Staff organise shopping trips with service users to purchase new items. Each individual has an allocated keyworker. Ensuring that people have sufficient clothes and toiletries is one responsibility of this role. Valued Lives has a policy regarding any cross gender personal care. This provides suitable safeguards for both users and staff. Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 17 There is a strong focus on health promotion, and also responding to any needs that do arise. All service users receive regular health monitoring. This includes dental and optical check ups. Any specialised services, such as speech therapy or occupational therapy, are also accessed as required. When significant health problems occur, it is clear that all possible steps are taken to secure treatment for these. Information about some of the main needs of individual service users is available for staff. One service user has experienced problems over recent months, with restricted mobility due to pain. The individual has already received some medical treatment, and is awaiting further input. In the meantime, they are sleeping downstairs. These temporary arrangements appear to be suitable. The home has now installed a ground floor shower, so that effective personal hygiene can be maintained. Since the previous inspection the organisation has had input from the local continence advisor. As a result, some changes have been made in the support given to any service users with needs in this area. There is ongoing liaison with the advisor. There has also been regular input from an occupational therapist, to give advice on suitable equipment and techniques to support the service user with decreased mobility. All appointments are undertaken in private, although a staff member will give assistance as needed. Records are kept of all contacts with any health professional. Medication is stored and recorded appropriately. Staff have received training in medication handling, and in some more specialised techniques. Changes to medication are documented and signed. Clear guidelines must be agreed with the prescriber for the use of ‘as required’ medication. These should be available for all staff to access. Since the previous inspection some progress has been made on drawing up the appropriate guidance. But it has not yet been finalised and implemented. Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are being protected from harm by the updating of key intervention guidelines. EVIDENCE: There is a wide range of information about adult protection issues. This includes details about multi-agency procedures within Wiltshire. A ‘Protection’ section in each individual’s care plan gives information about the various safeguards in place. These include recruitment checks, staff training, and key individual abilities and relationships that contribute to upholding someone’s welfare. Strategies for management of behavioural needs must contain appropriate guidance, show who has been involved in devising them, and be kept under regular review. As key elements of the overall support to people with complex and challenging needs, it is important to demonstrate that such guidance is regularly evaluated to ensure that it remains applicable, and is the best approach for that individual at that time. Progress has previously been made on this, with some individuals’ care managers signing up to various care plans and risk assessments. The organisation is now involving the local community learning disability nurse in the review of strategies. All service users have been referred for this input, which is to be given in order of identified priority. Physical interventions may be used with some service users on occasions. Individual guidelines describe the holds which may be used. Staff have received appropriate training in these techniques.
Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. The key standards in this section were met at the previous inspection. EVIDENCE: Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 Service users are supported by suitable numbers of staff. EVIDENCE: Each home within Valued Lives has some staff specifically allocated to it. Cover is then made up by other staff, who work in more than one setting. The owner’s aim is to employ sufficient people so that, even if they are one staff member down, there are still enough to cover all the organisation’s services without needing to rely on external agencies. Cashel Cottage has four staff who cover most of the shifts at the home. There are two people on duty for daytime shifts. They accompany service users when they go out for their planned daily activities. At nights, one person sleeps in. An on-call manager is available if required. Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 41 Quality assurance measures need further progress, to ensure the home is conducted and developed in line with service users’ needs and preferences. Effective record keeping is maintained, upholding service users’ best interests. The use of bed sides is supported by appropriate evidence of a suitable decision process, and monitoring of their safe operation. EVIDENCE: Progress has been made on the implementation of a quality assurance system. The organisation has condensed the tool purchased for this into a more manageable ten page booklet, which will form the basis of the approach to auditing all aspects of service delivery. Areas covered include customer focus, staff development, systems and processes. There are principles and quality indicators under each heading. The format includes scope for contributions from various stakeholders, such as service users, their families, and other Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 22 professionals who work with the organisation. When carrying out an audit, any deficits can be noted, along with the action to be taken in response. From completion of this quality audit, the organisation needs to generate a development plan. This can focus on any identified strengths and deficits, across all areas of service delivery. Goals for improvement can then be set, against which future progress can be measured. Detailed records are maintained for a range of areas relating to service user care. For the person who was very ill at the time of this inspection, there was a wide range of evidence of the care, monitoring and treatment being provided. Daily review sheets for each person contain effective ongoing records. Sampled files show detailed entries, including regular comment on key relevant issues. There are also clear notes made about all input from other professionals, whether by an actual consultation, or a telephone discussion. These records show the range of support which is accessed, demonstrating that all suitable steps are taken to help meet the needs of service users. Health and safety was not considered in detail at this inspection. However, a requirement of the additional inspection visit of November 2005 is met. One service user, currently sleeping downstairs due to decreased mobility, has bed sides in place overnight. There is a documented risk assessment to support this practice, covering all relevant factors. This is accompanied by written evidence of consent from the individual’s representative, which in this case is a family member. Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 N/A 3 3 4 N/A 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X X 2 X 3 X X Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 12-1,2,3 15 Requirement All service users must have individual plans and risk assessments reviewed and updated to reflect current needs and support. This part of Regulations also applies to the above Requirement. Guidelines must be available for the use of all ‘as required’ medications, to ensure that they are used within the prescriber’s instructions. (Timescale of 30/11/05 not met) This part of Regulations also applies to the above Requirement. There must be an annual development plan for the home. Timescale for action 30/04/06 1 2 YA6 YA20 17-1a Sch3-1b 12-1 13-2 30/04/06 30/04/06 2 3 YA20 YA39 17-1a Sch3-3m 24 30/04/06 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 25 1 YA6 Work should continue to develop the content and presentation of care plans, and associated information. COMMENT: This recommendation of the previous inspection was not checked at this visit. All service user documentation should be clearly signed and dated. COMMENT: This recommendation of the previous inspection was not checked at this visit. 2 YA41 Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cashel Cottage DS0000028392.V286034.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
